There is no such thing as a flat toe. This is not an injury where patients will be ready to go in two days. Instead, lateral ankle sprains require careful evaluation and management. The following are the main things to consider when dealing with spinal cord compression: delay the progression research for a few days; understand the course of the injury; conduct a comprehensive assessment when the patient can participate; patient compliance with treatment is important; and repeat testing is necessary when there is no improvement.
Lateral Ankle Sprain
Before choosing an intervention, clinicians should understand the basic guidelines for follow-up fractures including the following:
- Provide hands-on treatment
- Discuss expectations and timelines
- Expect compliance
- Respect pain
- Think again when there is no progress
- Order unnecessary imaging
- Have the patient maintain weight bearing when not necessary
- Order immobilisation when unnecessary
- Delay functional movements
- Provide insufficient rehabilitation
Lacerda et al found considerable heterogeneity in the literature regarding the classification system of lateral ankle sprains. Most systems use three levels to describe the severity of external ankle sprains:
- Easy: the patient is able to walk with significant swelling and pain. There are no strings involved.
- Moderate: the patient complains of pain when walking which is easier when walking and shows edema and moderate pain when palpating muscles. One ligament involved.
- Severe: the patient is unable to walk there is pain with daily activities there is severe swelling and pain to the touch. Two or more threads are involved.
Another system of labeling the hind toes uses 1 to 3 letters:
- Grade 1: little or no bleeding no point tenderness loss of function decreased total ankle motion by ≤ 5 degrees presence of swelling ≥ 0.5 cm.
- Grade 2: bleeding point tenderness present some loss of function reduced overall ankle motion by more than 5 degrees but less than 10 degrees and less than 2 cm of swelling.
- Grade 3: presence of moderate severe hemorrhage with near complete loss of function resulted in ≥ 10 degrees reduction in overall ankle motion and ≥ 2 cm of swelling.
Despite the availability of evidence-based research studies, there are differences in the management of posterior cattle fractures worldwide. It is therefore important to develop evidence-based international clinical guidelines accepted by all physicians treating hindlimb fractures. According to Green et al. most lateral ankle sprain protocols developed for different professions (athletic trainers nurses and physicians and physiotherapists) are outdated and of poor quality.
- Delay the full inspection for up to 14 days (4-14 days); a thorough preliminary assessment is not possible because patient participation is often limited by pain.
- The subjective interview should include the patient’s number of seizures (primary vs serial seizure(s)) location and severity of pain and mechanism of injury. The mechanisms of injury help to identify injured body systems and prioritize the clinical diagnosis.
- The assessment should include physical appearance of the patient’s ankle as well as the ability to stand up and accept weight on the injured foot and the degree of swelling.
Fractures usually occur as a result of inversion and internal rotation regardless of sagittal plane position: plantar flexion or dorsiflexion.
Examples of different mechanisms of injury and types of fractures:
- Forefoot adduction hindfoot inversion and tibial external rotation with the ankle in plantar flexion: one or more of the hindfoot muscles may be involved. It usually affects the anterior talofibular ligament and precedes the calcaneofibular ligament and the posterior talofibular ligament.
- External rotation of the foot and/or excessive ankle dorsiflexion: injury of distal tibiofibular syndesmosis (high ankle dislocation).
- Pronation–abduction pronation–external rotation or supination–external rotation of the foot: medial-ankle sprain.
- Extreme eversion injury: impingement of talus and lateral malleolus.
- Excessive plantar flexion and inversion: an injury to the lateral forefoot region known as cuboid syndrome when the cuboid bone moves out of alignment.
- Foot planted on the ground with ankle in dorsiflexion and inversion: closed packed position can produce compressive forces in mortise joints and shear forces. It causes injury to the hamstrings and the base of the fifth metatarsal. The peroneal nerve may also be involved.
Grades of Ankle Sprains
It can be established on the basis of an initial assessment following known guidelines (grades 1 to 3).
- PRICE (1-10 days):
- Protect: don’t lean your weight walking when you’re stuck.
- Rest (prevent further injury).
- Ice: begin within 36 hours with periodic application three times daily (10 minutes on/10 minutes off/10 minutes on). However with cryotherapy Vuurberg et al. found no improvement in rest-time pain activity or inflammation.
- Coercion: current evidence for the effectiveness of coercion is questionable. But clinicians are using bandages on Tubigrip and DVT stockings despite a lack of evidence of their effectiveness in terms of recovery.
- Improvement: there are no controlled trials of the effect of rest or elevation in managing acute ankle sprains. One protocol suggests elevating the heart by 15-25 cm to increase venous and lymphatic drainage and reduce inflammation.
- Early Mobilisation: gives good results when pain is respected and the patient is able to walk without stiffness and pain. Kerkhoffs et al found that early mobilization has the following advantages: shorter time to return to sport; significantly reduced inflammation; and radiographic reduction evidence of instability.
CAM Walker Moon Boot
- CAM Boot / Moon Boot or below-knee cast for protection until further examination can be completed:
- There is good evidence for semi-rigid and lace-up braces.
- Improve psychological confidence.
- Do not affect performance.
- Effective in reducing swelling.
- There is no evidence that long-term use of external support causes muscle “weakening” of the lower limbs.
Comprehensive Diagnosis and Comprehensive Treatment Section
The conservative period depends on the severity of the injury and is usually longer:
- 10 days in mild sprains
- 2-3 weeks in moderate sprains
- 6 weeks in severe sprains
The assessment must include:
- Muscle strength assessment
- Range of motion measurement
- Balanced Error Control System Test (BESS).
- Special tests, including:
- Foot and Ankle Ability Measurement (FAAM)
- Foot and Ankle Outcome Score (FAOS)
- Star Travel Balance Test (SEBT) .
- Pain behavior to help identify involved systems.
- Establish expectations and timelines to ensure patient compliance.
- If possible, mix it with other training.
- Use a lace-up brace to protect the ankle to maintain joint motion and limit dynamic joint positions such as maximum inversion. The brace should be worn during sports and daily activities and can be removed at night or off duty. Comparatively, the use of ankle braces has a better positive effect with plain sports tape or rigid kinesiotape.
- Monitor the patient.
- Provide manual therapy to stimulate hip movements in order to:
- Reduce faulty movement.
- Offer quality vs quantity.
- Use a pain-free approach.
In summary: exercise should not make the patient feel better.
- Functional rehabilitation is a form of treatment in which the function of the joint is preserved. These include:
- Closed chain activity exercises. Example: body movements on a firm base squats tandem stance lunges hop to stabilisation.
- Postural control and proprioception. Strategies include scheduling from simple to complex and predictable to unpredictable environmental constraints.
- The Star Excursion Balance Test (SEBT) assesses active postural control in patients with external ankle fractures.
- Motor learning strategies
- Cardiovascular fitness
- Leg strength training: leg strength influences somatosensory control of posture and balance. Short leg exercises (SFE) should be added early after proprioceptive re-training after ankle injury. Typically SFE training is conducted three times per week with three groups of 12 repeated statements. Each movement is held for 5 seconds and performed:
- Weeks 1-4 in a sitting position
- Weeks 5-8 in a standing position
- Weeks 5-9 in single-leg stance
Short Foot Exercises
- Increase the range of motion by extending and gathering arms. According to Izaola-Azkona et al. distal fibular mobilization with movement may be the most appropriate treatment option for acute lateral ankle sprain to achieve sustained daily living and athletic activities duty.
- Prevent faulty control techniques including drop landing  excessive hip strategy and faulty forefoot position.
- Evaluation of return to athletic rehabilitation.
If there is no improvement within six weeks the assessment should be repeated including:
- Review of the initial assessment.
- Review of the mechanism of injury.
- A review of intrinsic and extrinsic factors influencing recovery.
Based on the results of this new study, the following actions should be considered:
- Further investigation.
- Referral to a specialist (i.e. a doctor with a specialty in sports or orthopedic surgery).
- ↑ Jump up to:1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 1.23 1.24 1.25 Simpson H. Lateral Ankle Sprains. Plus Course 2022.
- ↑ Jump up to:2.0 2.1 Lacerda D, Pacheco D, Rocha AT, Diniz P, Pedro I, Pinto FG. CURRENT CONCEPT REVIEW: STATE OF ACUTE LATERAL ANKLE INJURY CLASSIFICATION SYSTEMS. The Journal of Foot and Ankle Surgery. 2022 Aug 18.
- ↑ Jump up to:3.0 3.1 3.2 3.3 3.4 Vuurberg G, Hoorntje A, Wink LM, Van Der Doelen BF, Van Den Bekerom MP, Dekker R, Van Dijk CN, Krips R, Loogman MC, Ridderikhof ML, Smithuis FF. Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline. British journal of sports medicine. 2018 Aug 1;52(15):956-.
- ↑ Jump up to:4.0 4.1 Green T, Willson G, Martin D, Fallon K. What is the quality of clinical practice guidelines for the treatment of acute lateral ankle ligament sprains in adults? A systematic review. BMC musculoskeletal disorders. 2019 Dec;20(1):1-3.
- ↑ Jump up to:5.0 5.1 5.2 5.3 5.4 5.5 Chen ET, Borg-Stein J, McInnis KC. Ankle Sprains: Evaluation, Rehabilitation, and Prevention. Curr Sports Med Rep. 2019 Jun;18(6):217-223.
- ↑ McGovern RP, Martin RL. Managing ankle ligament sprains and tears: current opinion. Open Access J Sports Med. 2016 Mar 2;7:33-42.
- ↑ Kaminski TW, Hertel J, Amendola N, Docherty CL, Dolan MG, Hopkins JT, Nussbaum E, Poppy W, Richie D; National Athletic Trainers’ Association. National Athletic Trainers’ Association position statement: conservative management and prevention of ankle sprains in athletes. J Athl Train. 2013 Jul-Aug;48(4):528-45.
- ↑ Jump up to:8.0 8.1 Kerkhoffs GM, van den Bekerom M, Elders LA, van Beek PA, Hullegie WA, Bloemers GM, de Heus EM, Loogman MC, Rosenbrand KC, Kuipers T, Hoogstraten JW, Dekker R, Ten Duis HJ, van Dijk CN, van Tulder MW, van der Wees PJ, de Bie RA. Diagnosis, treatment and prevention of ankle sprains: an evidence-based clinical guideline. Br J Sports Med. 2012 Sep;46(12):854-60.
- ↑ Jump up to:9.0 9.1 Goulart Neto AM, Maffulli N, Migliorini F, de Menezes FS, Okubo R. Validation of Foot and Ankle Ability Measure (FAAM) and the Foot and Ankle Outcome Score (FAOS) in individuals with chronic ankle instability: a cross-sectional observational study. Journal of orthopaedic surgery and research. 2022 Dec;17(1):1-7.
- ↑ Jump up to:10.0 10.1 Pierobon A, Raguzzi I, Soliño S, Salzberg S, Vuoto T, Gilgado D, Perez Calvo E. Minimal detectable change and reliability of the star excursion balance test in patients with a lateral ankle sprain. Physiotherapy Research International. 2020 Oct;25(4):e1850.
- ↑ Kemler E, van de Port I, Backx F, van Dijk CN. A systematic review on the treatment of acute ankle sprain: brace versus other functional treatment types. Sports Med. 2011 Mar 1;41(3):185-97.
- ↑ Jump up to:12.0 12.1 Helly KL, Bain KA, Hoch MC, Heebner NR, Gribble PA, Terada M, Kosik KB. The effect of attending physical rehabilitation after the first acute lateral ankle sprain on static postural control in patients with chronic ankle instability. Journal of Sport Rehabilitation. 2021 Mar 22;30(7):1000-7.
- ↑ Delahunt E, Bleakley CM, Bossard DS, Caulfield BM, Docherty CL, Doherty C, Fourchet F, Fong DT, Hertel J, Hiller CE, Kaminski TW, McKeon PO, Refshauge KM, Remus A, Verhagen E, Vicenzino BT, Wikstrom EA, Gribble PA. Clinical assessment of acute lateral ankle sprain injuries (ROAST): 2019 consensus statement and recommendations of the International Ankle Consortium. Br J Sports Med. 2018 Oct;52(20):1304-1310.
- ↑ Han K, Ricard MD, Fellingham GW. Effects of a 4-week exercise program on balance using elastic tubing as a perturbation force for individuals with a history of ankle sprains. J Orthop Sports Phys Ther. 2009 Apr;39(4):246-55.
- ↑ Hall EA, Chomistek AK, Kingma JJ, Docherty CL. Balance- and Strength-Training Protocols to Improve Chronic Ankle Instability Deficits, Part I: Assessing Clinical Outcome Measures. J Athl Train. 2018 Jun;53(6):568-577.
- ↑ Guzmán-Muoz E, Rodríguez SS, Concha-Cisternas Y, Badilla PA, Méndez-Rebolledo G. The effects of neuromuscular training on the postural control of university volleyball players with functional ankle instability: a pilot study. Archivos de medicina del deporte. 2020;36(5):283-7.
- ↑ Barnes RY, Raubenheimer J, Wilson M. Effect of core stability, M. gluteus medius and proprioceptive exercise programme on dynamic postural control in netball players. South African Journal for Research in Sport, Physical Education and Recreation. 2020 May 27;42(1):1-1.
- ↑ Khalaj N, Vicenzino B, Smith MD. Hip and knee muscle torque is not impaired in the first three months of a first-time lateral ankle sprain. Physical Therapy in Sport. 2022 Jan 1;53:1-6.
- ↑ de Ruvo R, Russo G, Lena F, Giovannico G, Neville C, Turolla A, Torre M, Pellicciari L. The Effect of Manual Therapy Plus Exercise in Patients with Lateral Ankle Sprains: A Critically Appraised Topic with a Meta-Analysis. Journal of Clinical Medicine. 2022 Jan;11(16):4925.
- ↑ Jump up to:20.0 20.1 Izaola-Azkona L, Vicenzino B, Olabarrieta-Eguia I, Saez M, Lascurain-Aguirrebeña I. Effectiveness of Mobilization of the Talus and Distal Fibula in the Management of Acute Lateral Ankle Sprain. Physical therapy. 2021 Aug;101(8):pzab111.
- ↑ Herb CC, Grossman K, Feger MA, Donovan L, Hertel J. Lower Extremity Biomechanics During a Drop-Vertical Jump in Participants With or Without Chronic Ankle Instability. J Athl Train. 2018 Apr;53(4):364-371.
- ↑ McGrath D, Patterson M, Persson UM, Caulfield B. Frontal-Plane Variability in Foot Orientation During Fatiguing Running Exercise in Individuals With Chronic Ankle Instability. J Athl Train. 2017 Nov;52(11):1019-1027.
- ↑ Smith MD, Vicenzino B, Bahr R, Bandholm T, Cooke R, Mendonça LD, Fourchet F, Glasgow P, Gribble PA, Herrington L, Hiller CE. Return to sport decisions after an acute lateral ankle sprain injury: introducing the PAASS framework—an international multidisciplinary consensus. British journal of sports medicine. 2021 Nov 1;55(22):1270-6.
- ↑ D’Hooghe P, Cruz F, Alkhelaifi K. Return to play after a lateral ligament ankle sprain. Current Reviews in Musculoskeletal Medicine. 2020 Jun;13(3):281-8.